Provider Demographics
NPI:1235475864
Name:DEGROOT, JENNIFER D (LPC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:DEGROOT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 NICOLE LN
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:54180-1219
Mailing Address - Country:US
Mailing Address - Phone:920-517-0906
Mailing Address - Fax:
Practice Address - Street 1:548 NICOLE LN
Practice Address - Street 2:
Practice Address - City:WRIGHTSTOWN
Practice Address - State:WI
Practice Address - Zip Code:54180-1219
Practice Address - Country:US
Practice Address - Phone:920-517-0906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4348-125101YM0800X
WI5568-120104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker